Provider Demographics
NPI:1134237894
Name:COLONIAL PHARMACY OF WHITESBORO INC
Entity type:Organization
Organization Name:COLONIAL PHARMACY OF WHITESBORO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SUPERVISING PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRAYTON
Authorized Official - Last Name:LANGDON
Authorized Official - Suffix:III
Authorized Official - Credentials:RPH
Authorized Official - Phone:315-736-2122
Mailing Address - Street 1:100 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:NY
Mailing Address - Zip Code:13492-1027
Mailing Address - Country:US
Mailing Address - Phone:315-736-2122
Mailing Address - Fax:315-736-7376
Practice Address - Street 1:100 MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITESBORO
Practice Address - State:NY
Practice Address - Zip Code:13492-1027
Practice Address - Country:US
Practice Address - Phone:315-736-2122
Practice Address - Fax:315-736-7376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025256332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02228999Medicaid
3324681OtherNCPDP
BC7689372OtherDEA
BC7689372OtherDEA